Clinical Research
Middle Mesial Canals in Mandibular Molars: Incidence
and Related Factors
Ali Nosrat, DDS, MS, Raney J. Deschenes, DMD, MS, Patricia A. Tordik, DMD,
M. Lamar Hicks, DDS, MS, and Ashraf F. Fouad, BDS, DDS, MS
Abstract
Introduction: Although the internal anatomy of
mandibular molars has been extensively studied, infor-
mation about middle mesial (MM) canals is limited.
The primary aim of this retrospective study was to eval-
uate the incidence of MM canals in mandibular first and
second molars. The secondary aim was to correlate the
incidence of MM canals with variables of molar type,
sex, age, ethnicity, and presence of a second distal ca-
nal. Methods: All mature permanent first and second
mandibular molars treated from August 2012 to May
2014 were included in the analysis. After completion
of root canal instrumentation in all main canals, the
clinician inspected the isthmus area of the mesial root
using the dental operating microscope. If there was a
catch point in this area with a file or explorer, the oper-
ator spent more time attempting to negotiate an MM ca-
nal. Results: Seventy-five mandibular first and
second molars were treated during the specified period.
Fifteen (20%) teeth had negotiable MM canals. The inci-
dence of MM canals was 32.1% in patients #20 years
old, 23.8% in patients 2140 years old, and 3.8% in pa-
tients >40 years. Analysis of data revealed a significant
difference in the distribution of MM canals among
different age groups (P < .05). The differences in the dis-
tribution of MM canals based on sex, ethnicity, molar
type, and presence of a second distal canal were not sig-
nificant. Conclusions: The incidence of negotiable MM
canals overall and their frequency of identification in
younger patients were higher than in previous reports.
(J Endod 2014;-:16)
Key Words
Dental operating microscope, isthmus, mandibular
molar, middle mesial canal, root canal anatomy
From the Department of Endodontics, Prosthodontics and
Operative Dentistry, School of Dentistry, University of Mary-
land, Baltimore, Maryland.
Address requests for reprints to Dr Ashraf Fouad, Depart-
ment of Endodontics, Prosthodontics and Operative Dentistry,
School of Dentistry, University of Maryland, 650 W Baltimore
Street, Baltimore, MD 21201. E-mail address: afouad@
umaryland.edu
0099-2399/$ - see front matter
Copyright 2014 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2014.08.004
JOE Volume -, Number -, - 2014
T he aim of root canal therapy is to eliminate all irritants from the root canal system.
These irritants include necrotic pulp tissue, microorganisms, and their byproducts.
A detailed knowledge of the pulp canal anatomy is necessary to effectively clean and
shape the root canal system. Mandibular molars are the most frequent tooth type to
be endodontically treated (1). Traditionally, mandibular molars are described as 2-
rooted teeth with 2 canals in the mesial root and 1 or 2 canals in the distal root (2).
However, studies have shown several variations in the anatomy of mandibular molars
that are thought to be determined by race and genetics (3). These variations include
a separate distolingual root (4), C-shaped anatomy of the roots and/or canals (5),
an isthmus between the mesiobuccal (MB) and mesiolingual (ML) canals (6), and a
third canal in the mesial root known as the middle mesial (MM) canal (7).
The reported prevalence of the MM canal in mandibular molars varies among
studies. Methods of detection include plastic casts (2), clearing (8), scanning electron
microscopy (9), microcomputed tomographic (mCT) imaging (10), and use of a file
under magnification (11).
Based on the method used, the prevalence of the MM canal ranged from 0% (2) to
36% (10). Clinical studies on negotiable MM canals show results different from studies
involving extracted teeth. Two older clinical studies reported an incidence of 2.6% and
12% for negotiable MM canals (7, 12).
Pomeranz et al (7) described the anatomy of MM canals as follows: (1) fin: The file
passes freely between the main mesial canal (ML or MB) and the MM canal (transverse
anatomies), (2) confluent: The MM canal originates as a separate orifice but apically
joins the MB or ML canal, and (3) independent: The MM canal originates as a separate
orifice and terminates as a separate apical foramen.
Clinical studies show that magnification significantly increases the probability of
locating and negotiating a second MB canal in maxillary molars (1315). Compared
with the dental operating microscope, there was no significant difference when loupes
were used (13). In an attempt to locate and negotiate MM canals in mandibular molars,
investigators showed in vitro that using the dental operating microscope can increase the
number of located and negotiated canals (11). To date, there are no studies that report
the incidence of negotiable MM canals in mandibular first and second molars using the
dental operating microscope. The primary aim of this study was to evaluate the incidence
of negotiable MM canals in mandibular first and second molars using the dental operating
microscope for magnification. The secondary aim was to correlate the incidence of MM
canals with variables including molar type (first or second mandibular molar), sex, age,
ethnicity, and the presence of a second distal canal.
Materials and Methods
The study period was from August 2012 to May 2014. All cases with mature first
and second permanent mandibular molars referred to the first author for nonsurgical
root canal treatment or retreatment and had treatment completed after informed con-
sent were included. The data were extracted from the Maryland endodontic record un-
der a protocol previously determined to be exempt by the Institutional Review Board at
the University of Maryland.
Root Canal Treatment Procedures
After local anesthesia and rubber dam isolation, carious dentin and all defective
restorations were removed. If there were no caries visible clinically or in bitewing
MM Canals in Mandibular Molars 1
Clinical Research
radiographs, the access cavity was prepared through the intact restora-
tion. Then, the main canals (ML, MB, distolingual, and distobuccal)
were located under 8 magnification using a Global G6 microscope
(Global Surgical Corporation, St Louis, MO). After negotiating these ca-
nals with a size #8 or #10 K-file (Dentsply Maillefer, Ballaigues,
Switzerland), coronal flaring was done with Gates Glidden drills (sizes
2, 3, and 4 [Dentsply Maillefer]). In retreatment cases, the previous
root canal filling material was removed with Gates Glidden drills (sizes
4, 3, and 2) in the coronal third. The apical two thirds of the root canal
filling material was removed using EndoSequence Rotary Files (Brass-
eler, Savannah, GA) operated at 1000 rpm. Then, the working length
was determined with an electronic apex locator (Root ZX II; J Morita
MFG Corp, Kyoto, Japan). Root canal preparation was followed by rotary
instrumentation using EndoSequence files using a crown-down tech-
nique and ending with a master apical rotary size 35/04 in the mesial
canals and 40/04 in the distal canal(s). The root canals were irrigated
by flooding them with 2.5% sodium hypochlorite (NaOCl) between each
file size. After completion of instrumentation of the main canals, they
were dried with sterile paper points. The pulpal floor was thoroughly
inspected under magnification and any isthmuses probed using either
#8 or #10 size C-files (Dentsply Maillefer) or an endodontic explorer.
If the tip of the C-file or explorer detected a catch in the isthmus area, the
clinician attempted to negotiate the MM canal with a watch-winding mo-
tion and slight apical pressure. After reaching the working length, the
MM canal was prepared to a slightly smaller size (usually 30/04)
than the main canals. Before obturation, the working length in all canals
was confirmed by taking a periapical radiograph with the correspond-
ing gutta-percha points fitted to the working length. An appropriate hor-
izontally angled radiograph was taken to visualize all mesial canals.
Then, all canals were obturated using cold lateral compaction of
gutta-percha in the apical third followed by vertical compaction of ther-
moplasticized gutta-percha (Calamus; Dentsply International, Johnson
City, TN). Final radiographs from 2 different angles were taken.
The number of MM canals was recorded for sex, ethnicity, age of
the patient at the time of treatment, molar type (first or second mandib-
ular molar), and presence/absence of a second distal canal. The Pom-
eranz classification of MM canals and the location of the MM canal
orifice were recorded also. Differences in the incidence of MM canals
were compared using the chi-square and Fisher exact tests. Statistical
analysis was performed using SPSS (Version 18; IBM, Armonk, NY). Sta-
tistical significance was set at P < .05.
Results
Seventy-five mandibular first and second molars were treated dur-
ing the 21-month period of the study. Of these, 15 (20%) molars had
negotiable MM canals. The distribution of MM canals based on sex, age,
ethnicity, molar type, and presence/absence of a second distal canal is
shown in Tables 1 and 2. The average age of the patients was 35 years.
There was a significant and progressive decrease in the inci-
dence of MM canals with age (Table 1) (c2 test, P < .05). There
were no statistical differences in the incidence of MM canals based
TABLE 1. The Frequency Distribution (%) of Middle Mesial Canals (MMCs) in Mandibular Molars (N = 75) Based on Sex, Age, and Ethnicity
Sex, n (%)
M F <20
With MMC 8 (23.5) 7 (17.1) 9 (32.1)
Without MMC 26 (76.5) 34 (82.9) 19 (67.9)
Total 34 41 28
F, female; M, male.
2 Nosrat et al.
on sex, ethnicity, or molar type (P > .05). A second distal canal
was present in 60% (9/15) of the teeth with an MM canal (9/15).
Eight mandibular first molars with an MM canal had 2 distal canals.
Only 1 mandibular second molar with am MM canal had 2 distal ca-
nals. Among teeth without an MM canal, 48.3% (29/60) had a second
distal canal. There was no significant difference in the presence of a
second distal canal between the teeth with an MM canal and those
without an MM canal (Fisher exact test, P > .05).
Among the 15 MM canals, 7 (46.7%) showed confluent anat-
omy, 3 (20%) showed independent anatomy, and 5 (33.3%) showed
fin anatomy (no separate orifice). Figures 13 through AD are
representative of each of these anatomies. One mandibular
second molar had 2 fins close to the ML and MB canals (Fig. 3). Among
those with separate orifices (10 teeth with confluent or independent
anatomy), 8 had an orifice close to the orifice of the ML canal, and 2
had an orifice close to the orifice of the MB canal. In those teeth with
confluent anatomy, 3 joined the ML canal, and 4 joined the MB canal.
Overall, 4% (2/50) of mandibular first molars had a second distal (dis-
tolingual) root, and 8% (2 of 25) of mandibular second molars had a C-
shaped anatomy.
Discussion
Failure of root canal treatment is related to the presence of bacte-
rial biofilm in the root canal system (16). If 1 aim of root canal treat-
ment is to remove all irritants from the root canal system, a missed canal
or an unclean root canal system can be a cause for treatment failure.
Persistent endodontic infection can be attributed to difficulties in
removing a bacterial biofilm from root canal ramifications, including
isthmuses (17).
The presence of isthmuses in the mesial root of mandibular molars
has been studied using different techniques. One in vitro study exam-
ined the apical 6 mm of the mesial root of 50 mandibular molars (18).
These roots showed isthmuses in 33% of the specimens at 35 mm from
the apex (18). However, none of the sections showed more than the 2
main canals. Using mCT reconstructions, Fan et al (19) investigated isth-
muses in the apical 5 mm of 126 mesial roots of mandibular first and
second molars. Isthmuses with different anatomies were present in 107
of 126 (85%) specimens. Some specimens had more than 1 isthmus in
the apical 5 mm. Harris et al (10) studied the internal anatomy of 22
mandibular molars using mCT reconstructions. An isthmus was present
in 100% of the specimens, and 36% had more than 2 canals. A system-
atic review, which included both in vitro and in vivo studies of the in-
ternal anatomy of mandibular first molars, showed isthmuses present in
54.8% of the mesial roots (20). Fifteen studies were included in this re-
view with a collective sample size of 1615 teeth. However, none of these
studies reported whether isthmuses were clinically negotiable. Never-
theless, they provide sufficient evidence to show that there is a high
probability of having uncleaned areas in the mesial root of mandibular
molars after root canal treatment.
Using an endoscope to examine resected root ends, von Arx et al
(21) studied 144 failed root canaltreated teeth that subsequently
Age, n (%) Ethnicity, n (%)
2140 >40 Black White Hispanic
5 (23.8) 1 (3.8) 8 (27.6) 5 (12.2) 2 (40)
16 (76.2) 25 (96.2) 21 (72.4) 36 (87.8) 3 (60)
21 26 29 41 5
JOE Volume -, Number -, - 2014
 Clinical Research
TABLE 2. The Frequency Distribution (%) of Middle Mesial Canals (MMCs) in aged 2039 years compared with 24% in patients older than 60. They
Mandibular Molars (N = 75) Based on Molar Type and Presence/Absence of a also showed that the average ratio of a partial isthmus to a complete
Second Distal Canal isthmus increased with age (6). These findings are consistent with
Second distal the results of our study. These findings indicate that clinicians should
canal, n (%) Molar type, n (%) spend more time evaluating the pulp chamber floor area between the
MB and ML canals to search for an isthmus when treating mandibular
First Second first and second molars of younger patients.
With Without molar Molar Our data showed no significant difference in the incidence of MM
With MMC 9 (60) 6 (40) 11 (22) 4 (16) canals among different ethnic groups. Larger populations of known
Without MMC 29 (48.3) 31 (51.7) 39 (78) 21 (84) ethnic backgrounds are needed to show whether there is a level at which
Total 38 37 50 25 any differences become statistically significant. However, there was a
considerable difference in the number of MM canals between whites
and nonwhites. The incidence of MM canals in the white population
underwent root end surgery. They observed the highest percentage of was 12.2% (5 of 41), which is consistent with the findings of Pomeranz
isthmuses in the mesial root of mandibular molars (88.5%). Toure et al (7). The incidence of MM canals in nonwhites (blacks and His-
et al (22) showed that more mandibular molars were extracted after panics) was 29.4% (10/34).
root canal treatment than any other tooth type. In addition, the second Susin et al (23) showed that cleaning of isthmuses and intercom-
most common reason (20%) for extraction of mandibular molars was munications between root canals in 1 root is clinically challenging. They
failure of endodontic treatment. It is possible that the identification, fol- showed that negative apical pressure using EndoVac (SybronEndo, Or-
lowed by the cleaning and shaping of MM canals, could lead to a reduc- ange, CA) removed considerably more debris from the isthmuses than
tion in irritants emanating from the complex root canal anatomy of manual dynamic irrigation with NaOCl and EDTA 17% (23). The effect
mesial roots of mandibular molars. Thus, the number of failures of of active ultrasonic irrigation, using NaOCl as an irrigant, on the clean-
nonsurgical root canal treatment in these teeth might be reduced. liness of the isthmus area in mandibular molars in vivo has been re-
A clinically significant finding in our study was a higher incidence ported (24, 25). When active ultrasonic irrigation was added to
of negotiable MM canals in younger patients. Patients aged 20 years or conventional hand/rotary instrumentation during canal cleaning and
younger showed an incidence of 32.1% for negotiable MM canals in shaping, both histologic and microbiological assessment showed
mandibular molars. Gu et al (6) studied the isthmus anatomy of 36 significantly cleaner isthmus areas in the apical 13 mm (24, 25).
mandibular first molars in vitro using mCT reconstructions. They Although these studies used noninvasive techniques to clean the
showed a significantly higher prevalence (50%) of isthmuses in patients isthmus area, none of them evaluated the amount of bacterial

Figure 1. (A) A preoperative view of tooth #30 in a 20-year-old black man. (B) A distal angle radiograph after obturation. The orifice of the MM canal is located
close to the MB canal orifice. The MM canal showed confluent anatomy and joined the ML canal in the apical third. (C) A straight-on view of the tooth after
obturation. (D) A magnified view (8) of the 3 mesial canals.

JOE Volume -, Number -, - 2014 MM Canals in Mandibular Molars 3

Clinical Research
Figure 2. (A) A preoperative radiograph of tooth #30 in a 16-year-old black man. (B) A distal angle radiograph after obturation. The MM canal orifice is located
close to the orifice of the MB canal. The MM canal showed a separate apical foramen (independent anatomy). (C) A mesial angle radiograph after obturation. (D)
A magnified view (8) of the 3 mesial canals.
reduction in the complex root canal system. In an in vitro study on the
effectiveness of Self Adjusting Files (ReDent Nova Ltd, Raanana, Israel)
in removing bacterial biofilm from the mesial root of mandibular
molars, no difference between Self Adjusting Files and other rotary
files was found (26).
The negotiation of MM canals with hand/rotary files provides ac-
cess for irrigating solutions into the otherwise inaccessible isthmus. We
hypothesize that negotiation and chemomechanical preparation of the
isthmus area can substantially reduce the bacterial biofilm and bacterial
load. We also hypothesize that this reduction in bacterial biofilm may
improve the outcome of nonsurgical root canal treatment in mandibular
molars. Clinical outcomes studies with long-term follow-ups are needed
to test these hypotheses.
Anatomic variations of mandibular molars such as the distolingual
root/canal and C-shaped root/canal anatomy are well recognized by end-
odontic clinicians. Studies have shown an overall prevalence of 13% for
distolingual root in mandibular first molars (20) with a higher preva-
lence of 22% (4) to 28.5% (27) in Asian ethnic groups. Studies have
shown a prevalence of 10%31.5% for C-shaped anatomy in mandibular
second molars in different Asian populations (5, 28). However, in this
study, the prevalence of a distolingual root and C-shaped anatomy was
less than other reports. This may be related to the fact that no patients
of Asian heritage were included in the patient sample.
In contrast, data on the incidence/prevalence of MM canals are
limited. Clinical studies on the incidence of negotiable MM canals are
limited to those performed in the 1980s without using magnification
(7, 12). Pomeranz et al (7) reported the highest incidence (12%). It
is now well documented that using magnification enhances the clini-
4 Nosrat et al.
cians ability to visualize the anatomy of the pulp chamber (11, 14).
Our study is the first in vivo evaluation of the incidence of MM
canals using the dental operating microscope. The high incidence
(20%) of MM canals in this study is likely attributable to the use of
the microscope.
Several of our anatomic findings regarding MM canals are
consistent with other studies. Pomeranz et al (7) reported that the
orifice of the MM canal was always located close to the ML canal.
Our findings were similar for the majority of teeth with a separate
MM orifice (8/10). Only 2 of 10 (20%) of teeth had the orifice of
the MM canal located near the MB canal (Figs. 1 and 2). Our
findings were also consistent with the observations made under
magnification in a recent ex vivo study on extracted mandibular
molars (11). A separate apical foramen for an MM canal was a
rare finding (7, 11, 12). Nevertheless, in the present study, 20%
(3/15) of the MM canals had a separate apical foramen
(independent anatomy). Pomeranz et al (7) reported that the
most prevalent anatomy was a fin (67%). Karapinar-Kazandag
et al (11) found that all MM canals showed a confluent anatomy.
No independent or fin anatomy was found. In our study, the
most prevalent (46.7%) anatomy was confluent.
In conclusion, using magnification and careful tactile search tech-
niques, the incidence of MM canals in mandibular molars was found to
be higher than previously reported. The probability of finding and nego-
tiating an MM canal in younger patients is significantly higher than in
older individuals. Using the operating microscope is key to locating
and negotiating MM canals. Clinical studies with long-term follow-ups
are needed to determine the effect of preparation of MM canals on
JOE Volume -, Number -, - 2014

Figure 3. (A) A preoperative view of tooth #31 in an 18-year-old white man. (B) A distal angle view of the gutta-percha cone fit. There are 2 fins in the mesial
root adjacent to the MB and ML canals. (C) A mesial angle radiograph after obturation. (D) A magnified view (8) of the access cavity. Note the presence of fins
adjacent to the MB and ML canals.
the outcome of nonsurgical endodontic treatment in mandibular first
and second molars.
Acknowledgments
The authors deny any conflict of interest related to this study.
References
1. Hull TE, Robertson PB, Steiner JC, del Aguila MA. Patterns of endodontic care for a
Washington state population. J Endod 2003;29:5536.
2. Skidmore AE, Bjorndal AM. Root canal morphology of the human mandibular first
molar. Oral Surg Oral Med Oral Pathol 1971;32:77884.
3. Curzon ME. Miscegenation and the prevalence of three-rooted mandibular first mo-
lars in the Baffin Eskimo. Community Dent Oral Epidemiol 1974;2:1301.
4. Huang RY, Cheng WC, Chen CJ, et al. Three-dimensional analysis of the root
morphology of mandibular first molars with distolingual roots. Int Endod J 2010;
43:47884.
5. Zhang R, Wang H, Tian YY, et al. Use of cone-beam computed tomography to eval-
uate root and canal morphology of mandibular molars in Chinese individuals. Int
Endod J 2011;44:9909.
6. Gu L, Wei X, Ling J, Huang X. A microcomputed tomographic study of canal isth-
muses in the mesial root of mandibular first molars in a Chinese population.
J Endod 2009;35:3536.
7. Pomeranz HH, Eidelman DL, Goldberg MG. Treatment considerations of the middle
mesial canal of mandibular first and second molars. J Endod 1981;7:5658.
8. Gulabivala K, Aung TH, Alavi A, Ng YL. Root and canal morphology of Burmese
mandibular molars. Int Endod J 2001;34:35970.
9. Navarro LF, Luzi A, Garcia AA, Garcia AH. Third canal in the mesial root of perma-
nent mandibular first molars: review of the literature and presentation of 3 clinical
reports and 2 in vitro studies. Med Oral Patol Oral Cir Bucal 2007;12:E6059.
10. Harris SP, Bowles WR, Fok A, McClanahan SB. An anatomic investigation of the mandib-
ular first molar using micro-computed tomography. J Endod 2013;39:13748.
JOE Volume -, Number -, - 2014
Clinical Research
11. Karapinar-Kazandag M, Basrani BR, Friedman S. The operating microscope en-
hances detection and negotiation of accessory mesial canals in mandibular molars.
J Endod 2010;36:128994.
12. Fabra-Campos H. Three canals in the mesial root of mandibular first permanent mo-
lars: a clinical study. Int Endod J 1989;22:3943.
13. Buhrley LJ, Barrows MJ, BeGole EA, Wenckus CS. Effect of magnification on locating
the MB2 canal in maxillary molars. J Endod 2002;28:3247.
14. Baldassari-Cruz LA, Lilly JP, Rivera EM. The influence of dental operating micro-
scope in locating the mesiolingual canal orifice. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2002;93:1904.
15. Rampado ME, Tjaderhane L, Friedman S, Hamstra SJ. The benefit of the operating
microscope for access cavity preparation by undergraduate students. J Endod 2004;
30:8637.
16. Ricucci D, Siqueira JF Jr, Bate AL, Pitt Ford TR. Histologic investigation of root canal-
treated teeth with apical periodontitis: a retrospective study from twenty-four pa-
tients. J Endod 2009;35:493502.
17. Nair PN. On the causes of persistent apical periodontitis: a review. Int Endod J 2006;
39:24981.
18. Teixeira FB, Sano CL, Gomes BP, et al. A preliminary in vitro study of the incidence
and position of the root canal isthmus in maxillary and mandibular first molars. Int
Endod J 2003;36:27680.
19. Fan B, Pan Y, Gao Y, et al. Three-dimensional morphologic analysis of isthmuses in
the mesial roots of mandibular molars. J Endod 2010;36:18669.
20. de Pablo OV, Estevez R, Peix Sanchez M, et al. Root anatomy and canal configuration
of the permanent mandibular first molar: a systematic review. J Endod 2010;36:
191931.
21. von Arx T, Steiner RG, Tay FR. Apical surgery: endoscopic findings at the resection
level of 168 consecutively treated roots. Int Endod J 2011;44:290302.
22. Toure B, Faye B, Kane AW, et al. Analysis of reasons for extraction of endodontically
treated teeth: a prospective study. J Endod 2011;37:15125.
23. Susin L, Liu Y, Yoon JC, et al. Canal and isthmus debridement efficacies of two irri-
gant agitation techniques in a closed system. Int Endod J 2010;43:107790.
24. Gutarts R, Nusstein J, Reader A, Beck M. In vivo debridement efficacy of ultrasonic
irrigation following hand-rotary instrumentation in human mandibular molars.
J Endod 2005;31:16670.
MM Canals in Mandibular Molars 5
Clinical Research
25. Burleson A, Nusstein J, Reader A, Beck M. The in vivo evaluation of hand/rotary/ultra-
sound instrumentation in necrotic, human mandibular molars. J Endod 2007;33:7827.
26. Siqueira JF Jr, Alves FR, Versiani MA, et al. Correlative bacteriologic and micro-
computed tomographic analysis of mandibular molar mesial canals prepared by
self-adjusting file, reciproc, and twisted file systems. J Endod 2013;39:104450.
6 Nosrat et al.
27. Kim SY, Kim BS, Woo J, Kim Y. Morphology of mandibular first molars analyzed by
cone-beam computed tomography in a Korean population: variations in the number
of roots and canals. J Endod 2013;39:151621.
28. Jafarzadeh H, Wu YN. The C-shaped root canal configuration: a review. J Endod
2007;33:51723.
JOE Volume -, Number -, - 2014